2/7/2018. Minimally-invasive Mitral Valve surgery at NYU

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1 Department of Cardiothoracic Surgery Mitral Valve Surgery in the 21 st Century Eugene Grossi, MD SB Colvin Professor of Cardiothoracic Surgery Didier Loulmet, MD Director of Robotic Surgery NYU 22nd Annual Coastal Cardiac &Vascular Conference February 17, 2018 Mitral Valve Surgery in the 21 st Century ANTICIPATED ADVANTAGES Decreased pain and overalltrauma Less blood, eliminate sternal infections Decreased hospital stay / recoverytime Better cosmetics and patient satisfaction Minimally-invasive approaches originally received a lot of pushback, many surgeons felt they were being pushed out of their comfort zone 2 Minimally-invasive Mitral Valve surgery at NYU 1994: NYU and Stanford publish experimental work on port access with very encouarging results In the following years, NYU remained at the forefront of minimally-invasive mitral surgery 3 1

2 Mitral Valve Surgery in the 21 st Century Originally pure Port Access 1. Mini-thoracotomy 2. Peripheral or percutaneous bypass 3. Balloon endo-aortic occlusion 4. Percutaneous coronary sinus catheter 4 Mitral Valve Surgery in the 21 st Century Obstacles to widespread adoption: 1. Too complex for great proportion of institutions 2. Learning curve steep in some instances 3. Ancillary staff needs extra training 4. Relied on retrograde arterial perfusion 5. Too expensive 5 Mitral Valve Surgery in the 21 st Century Evolution of the NYU approach: 2000s 1. Conceptually simplify as much as possible 2. Limit robotics and endoscopes 3. Put operation totally in the hands of the surgeon using conventional tools under direct vision 4. Routine antegrade arterial perfusion 5. Cut costs and OR times 6 2

3 Set-up for Minimally-invasive direct MVsurgery Mini-thoracotomy (3rd or 4th interspace) Direct ascending aorta cannulation Femoral venous cannulation Direct external crossclamp Conventional retrograde cardioplegia CO2 field flooding 7 Minimally-invasive MV surgery at NYU Procedures and techniques Initial Experience 8 Sternotomy vs Right Thoracotomy formv surgery 9 3

4 Sternotomy vs Right Thoracotomy formv surgery No compromise in Repair Complexity All Repairs N = 1601 Sternotomy N = 530 R Thoracotomy N = 1071 P= Anterior resection 380 (23.7%) 75 (14.2%) 305 (31.5%) <0.001 Any anterior leaflet procedure 493 (30.8%) 140 (26.4%) 353 (33.0%) 0.01 Annuloplasty device Posterior leaflet resection 1601 (100%) 530 (100%) 1071 (100%) NA 1207 (75.4%) 385 (72.6%) 822 (76.8%) 0.07 Sliding plasty 18 (1.1%) 5 (0.9%) 13 (1.2%) NYU Folding plasty School of Medicine 588 (36.7%) 68 (12.8%) 520 (48.6%) <0.002 Can complex mitral valve repairbe performed with robotics? What is a complexrepair? Can we perform complex repairs with robotics? What can weaccomplish? 11 What makes MV repair difficult? Lack of leaflet tissue Bad quality of tissue The extent of lesions (number of segments involved) Limited exposure The type of techniques we use to treat the lesions: - Level I complexity - Level II complexity - Level III complexity 12 NYU School of Me- dicinelevel IV complexity 4

5 History -Robotics and themitral Valve late 1990s Paris NewYork Robotics and themitral Valve late 1990s Technology not quite there Lacking: - exposure tools - facilitating suture tech - good results Both groups stepped back from robotic mitrals WR Chitwood pursued with mini-thoracotomy robotic assisted approach NYU 2 surgeons became colleagues 2012 started a team for total endoscopic robotic mitral program. For 3 months we retrained with clinical scenarios, simulations, wet lab courses,& expert observation. We refused to compromise integral parts ofoperation: Cardioplegic arrest Use of annuloplasty device 5

6 Totally endoscopic robotic mitral repair (TERMVR): could not afford a significant learning curve practice in the competitive environment of New York Training Dedicated Team Commitment (Institutional) Team Participants Communication no music Process Control Attention to detail Team Brief / Debrief Model Totally Endoscopic Robotic Mitral Repair:TERMVR Training Dedicated Team Commitment (Institutional) Team Participants Communication no music Process Control Attention to detail Team Brief / Debrief Model TERMVR Operating Room Management 17 Mitral Valve Surgery in the 21stCentury Can complex mitral repair be performed using robotics?a universal approach for 500 patients This reports our experience with 500 consecutive patients (May 201 -August 2017) who had intent-to-treat totally endoscopic robotic mitral valve repair with a focus on complex MV pathologies, concomitant procedures, and analysis of patientsnot offered this approach. 18 6

7 Preop Evaluation Preop eval CTAC-A-P 8-12% change (minor / major) in monitoring / operative strategy 2.5 cm incision groin Seldinger technique and echocardiographic guidance for cannula and endo-balloon placement No fluoroscopy/x-ray used If occlusive aortic disease axillary perfusion Current OR Plan Single lumen endotracheal tube (except reoperations, prior right chest surgery) Bilateral radial a-lines Right arm dropped below bed on floating board 2-3 egg crate foam under right hemithorax RIJ Triple lumen; if >1+AI coronary sinus cardioplegia catheter; or at least 1x week Port Placement Working port and scope in same interspace (3rd) XX-Small Alexis soft tissue retractor have to force index finger thru to check interspaces Left arm 2 nd Right arm 6 th Retractor arm medial 7

8 Aortic Endoclamp Balloon-tipped catheter inserted via femoral artery and inflated 2cm above the sinotubular junction Systemic perfusion of oxygenated blood with isolation of the heart from back-bleeding Fluorescence endoballoon guidance Endoscopic robotic mitral repair in a patient with severe pectus excavatum 24 8

9 Robotic Mitral Repair (500 patients: May 201 August 2017) Patient characteristics Age 60.8 Men 314 (62.8%) Women 186 (37.2%) 25 Robotic Mitral Repair (500 patients: May 2011 August2017) Etiologies, MV Repair Techniques, and ConcomitantProcedures. Etiologies n (%) Barlow s 340 (68) Fibroelastic 42 (8.4) deficiency Functional 37 (7.4) Inflammatory 22 (4.4) Healed 17 (3.4) endocarditis Other 42 (8.4) Repair techniques n (%) Posterior leaflet 274 (54.8) Bileaflet 79 (15.8) MAC excision 61 (12.2) Annuloplasty alone 55 (1.0) Anterior leaflet 31 (6.2) Concomitant Procedures n (%) Left appendage closure 474 (94.8) PFO/ASD closure 98 (19.6) Cryoablation 97 (19.4) Hybrid PCI 39 (7.8) revascularization Tricuspid repair 31 (6.2) Posterior leaflet repair n Triangular excision-suture 194 Quadrangular excision 165 Hemisliding plasty 105 Classic sliding plasty 38 Folding plasty 2 Annulus plication 5 Posterior subvalvular repair n Artificialchord implant 67 MAC e xcis ion 61 A-V groove patch repair 19 P1-P2 or P2-P3 cleft closure 124 Bovine patch augmentation

10 Anterior leaflet Triangular excisionsuture Alfieri stitch Closure of an aberrant cleft Bovine patch augmentation Plication of the margin n Anterior subvalvular Secondary chordae division PM repositioning Artificial chordae Chordal transfer Aberrant muscle band excision n Combined procedures LA appendage closure n 474 % 94.8 PFO or ASDclosure CryoMaze Hybrid revascularization Tricuspid annuloplasty Complexity Scores Complexity 1 Complexity 2 Complexity 3 Complexity

11 Cross-clamp time for isolated MV repairs: minutes Conversion to sternotomy: 7/500 (1.4%) Extubation in OR: 320/500 (64%) Stroke rate: 6/500 (1.2%) 30-day mortality: 2/500 (0.4%) Complexity of repair had no effect on length of stay or residual MR Post-operative echo showed mild residual regurgitation or less in 496/500 (99.2%) 47% patients discharged by POD 3 32 Repair rate in degenerative diseases 100% Conversion to sternotomy 1.4% OR extubation 64% 30-day mortality 0.4% 33 11

12 Mitral Valve Surgery in the 21st Century Who did we not attempt with robotics? (500 patients: May 201 August 2017) Which patients were not offered the robot approach in the past 3 years? 26/347 patients (7.5%) had isolated MV operations via sternotomy by our two robotic surgeons 15 had prior cardiac surgery, 12 had priormv surgery Calcific stenosis or MAC present in 9 patients Who did we notattempt with robotics? (500 patients: May 201 August 2017) Who did we notattempt with robotics? (500 patients: May 201 August 2017) 12

13 Who did we not attempt with robotics? 3 rd time cardiac operation for severe MR Mitral Valve Surgery in the 21 st Century Minimally Invasive Valve (500 patients: May 201 August 2017) Has been a 25 year journey Basic approaches remain thesame Changes in the technology along the way Benefit for out patients THANK YOU 13